Team Member Questionaire {required}

Mission Team Questionnaire (this must be returned with the Application and Medical Release forms)

Name:
Address:


Phone: (with area code)
Date of Birth: (under 18 need permission slip signed by parent or guardian)

Email address: (very important)




Do you have any health issues that we should be familiar with? (please give dates relevant to strokes, heart attacks, or other health issues that may be persistent or chronic) What, if any medications are you currently taking?


Do you have any allergies (food or otherwise)?
If yes, do you carry medication with you for this at all times? If no: what is that medication(s)?

If you have allergies, when was the last time (date) that you had an issue with this problem?

Do you know of any other health issues that we should know about for your protection and/or the safety of others?

Have you ever suffered from shortness of breath or other lung or breathing problems?

Do you have a preference of a roommate IF we should be able to arrange it?


Do you understand that you will need to drink only bottled water that will be provided there?

Do you understand that you will not have food choices and that you will need to be ready to eat whatever SCORE provides?


Do you know anything about Animistic Beliefs?


We must be culturally sensitive while NOT compromising the essentials of the Christian Faith. These areas may be remote and can be very dark spiritually. Will you commit to pray daily for these people and for your team – before, during and after the Mission here (beginning today)?

Accommodations may be like none you've experienced before. Please prepare yourself mentally and physically for this reality.

Your safety and health are one of our primary concerns. Will you promise to carefully adhere to these guidelines?

Signed:___________________________________________ Date: ____________________

Pastor Sign to show your approval of this applicant for this mission:___________________________ Date:____________

Mission Team Check List

Missions Check List

Normal toiletries (toothpaste, deodorant, shampoo, etc.)
Liquid hand soap
Antibacterial waterless hand cleaner
Bug repellant
Hand and body lotion
Chapstick
Visine type eye drops
Suntan lotion (very high sun block factor)
Lotion or “utterbutter” type cream (moisturizer)
Towel and washcloth
Small first aid kit

Hiking boots or shoes (comfortable tennis shoes are OK)
one general pair of dress shoes

Backpack or fanny pack with water bottle(s)

(MARK WITH LONG WIDE YELLOW RIBBON)
(MARK WITH LONG WIDE YELLOW RIBBON)



Camera
Video
Binoculars
Ball point pen
Small note pad
Journal
Bible
Layered clothing
Windbreaker (light-weight raincoat with hood)
Cap or hat
Blue jeans
Dress Shirt (short sleeve OK) & tie
One pair of Dress pants
Women: please wear skirts or dresses for ministry events!
NO sandels or open-toed shoes!
NO tight or low-cut blouses or tank tops


Music or short message AND testimony for Worship services
Any lessons or materials YOU need in order to perform your purposed mission (teaching or medical materials, etc.)

Things to put in your CHECKED luggage:
Fingernail clippers; file
Small flashlight

"311" for Carry-on luggage: any liquid/gel type toilitry much be only 3 oz. and together in a 1-quart zip-lock bag (1 per passenger)

Things WE need prior to Mission
* list of your spiritual gifts
*Application / Medical Release Form
* A written personal testimony (about 1 double spaced typed page [2-5 min.])
Copy of:
Medical insurance documentations
Passport

Application / Medical Release Form

The Charthouse
Missions Participation
Parent Permission/Medical Release
And Indemnification Agreement
http://missionforchrist.blogspot.com/

I, the undersigned, am the parent/legal guardian of the minor child named below and am at least 18 years of age. I am signing this document (release) on my own behalf and on behalf of my child.

I hereby give permission for my child, _______________________________________________, (print name of child)
to participate in missions with Belview Baptist Church. I understand that there are risks involved in missions. By signing this release, my child and I agree to accept any and all such risks and voluntarily elect to participate in this mission. We understand that due to these risks the conduct of my child is of utmost importance. My child agrees to abide by all rules of conduct whether written or spoken. I understand that if my child should behave inappropriately or become disruptive during this mission, that I the parent/legal guardian will be responsible for all cost involved in returning my child to their home.


In consideration of allowing my child to participate in missions with Belview Baptist, I assume all risks associated with my child’s participation. Additionally, I hereby agree to hold harmless, release, defend and indemnify Belview Baptist and/or claims I may make arising from injury or death to persons or damage to property in any way related to my child’s participation in this mission, including those injuries and damages caused by any released party’s alleged or actual negligence. I also agree to defend and indemnify each released party for any and all such claims a third party may make which are in any way related to my child’s participation.

I authorize any released party to call for medical care for my child and/or to transport my child to a hospital or other medical facility if, in the opinion of such released party, medical attention is needed for my child. I understand that an effort will be made to locate me in the event of such an emergency, but, if it is not possible to locate me, I authorize medical care providers to provide any emergency care to my child. I agree that, upon my child’s transport to any such hospital or other medical facility, no released party shall have any further responsibility for my child. Further, I agree to pay all costs associated with such medical care and related transportation provided to my child and shall indemnify each released party from incurred costs therefore.

I consent and authorize the use and reproduction, for any purpose and without compensation, of all images taken of child while engaged in above listed activity.

I promise that I will inform Belview of any known medical condition that my child may suffer which may affect my child’s ability to participate in this mission. I will also provide any medications that may be necessary for my child while he participates.

List any important health information (e.g. prescription medications, allergies, dietary restrictions, chronic physical problems, etc.):

_______________________________________________________________________________________________________________

List any special habits, needs, or fears:

_______________________________________________________________________________________________________________

I HAVE CAREFULLY READ THIS RELEASE, UNDERSTAND ITS CONTENTS,
AND SIGN IT WITH FULL KNOWLEDGE OF ITS SIGNIFICANCE.

Executed this _______ day of _____________________________, 200___.


______________________________________________ ___________________________________________
Printed Name of Parent/Legal Guardian Signature of Parent/Legal Guardian


_________________________________________________________ _____________________________________________________
Emergency Contact Name Date Emergency Contact Phone


Created on 12/16/2004 1:25:00 PM